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Esophagoscopy, flexible, transoral, is a medical procedure that involves the use of a flexible endoscope to visualize the esophagus. This procedure is specifically designed for the removal of tumors, polyps, or other lesions using a snare technique. The flexible endoscope is introduced through the mouth and carefully advanced into the esophagus, allowing for a thorough examination of the velopharyngeal closure, the base of the tongue, and the hypopharynx. During the procedure, the motion of the vocal cords is observed, and the pharyngeal musculature is evaluated to ensure proper function. As the endoscope reaches the cricopharyngeus, the patient may be instructed to burp or swallow, which aids in the smooth passage of the scope through the esophagus to the gastroesophageal junction. Any abnormalities encountered during this examination are meticulously noted. Following the identification of the tumor, polyp, or lesion, the procedure utilizes a wire snare loop, which is placed around the targeted lesion. This loop is then heated to effectively shave off and cauterize the lesion. The removal of lesions can be performed in one single placement of the snare, known as en bloc removal, or in a piecemeal fashion, which necessitates multiple applications of the snare technique. This procedure is critical for diagnosing and treating various esophageal conditions, ensuring that any abnormal growths are safely excised while minimizing potential complications.
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Esophagoscopy, flexible, transoral, with removal of tumor(s), polyp(s), or other lesion(s) by snare technique is indicated for the following conditions:
The procedure begins with the patient positioned appropriately to facilitate the introduction of the flexible endoscope. The endoscope is carefully inserted through the mouth and advanced into the esophagus. During this process, the physician examines the velopharyngeal closure, the base of the tongue, and the hypopharynx to assess any abnormalities. Vocal cord motion is observed, and the pharyngeal musculature is evaluated to ensure proper function. As the endoscope reaches the cricopharyngeus, the patient may be instructed to perform a burp or swallow maneuver, which aids in the smooth passage of the endoscope through the esophagus to the gastroesophageal junction. Once the endoscope is fully advanced, any abnormalities, such as tumors, polyps, or lesions, are meticulously noted. After identifying the lesion, a wire snare loop is placed around it. The snare is then heated, allowing for the lesion to be shaved off and cauterized simultaneously. This technique can be performed in two ways: en bloc removal, where the lesion is removed in one single placement of the snare, or piecemeal removal, which requires multiple applications of the snare to completely excise the lesion.
After the completion of the esophagoscopy and removal of the lesion, the patient is monitored for any immediate complications. Post-procedure care may include instructions regarding diet, activity level, and signs of potential complications such as bleeding or infection. Patients are typically advised to avoid certain foods or activities for a specified period to allow for proper healing. Follow-up appointments may be scheduled to assess recovery and discuss pathology results if biopsies were taken during the procedure. It is essential for healthcare providers to provide clear post-procedure instructions to ensure optimal recovery and to address any concerns the patient may have.
| Short Descr | ESOPHAGOSCOPY SNARE LES REMV | Medium Descr | ESOPHAGOSCOPY FLEXIB LESION REMOVAL TUMOR SNARE | Long Descr | Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique | Status Code | Active Code | Global Days | 000 - Endoscopic or Minor Procedure | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 3 - Special payment adjustment rules for multiple endoscopic procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Endoscopic Base Code | 43200 Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P8B - Endoscopy - upper gastrointestinal | MUE | 1 | CCS Clinical Classification | 70 - Upper gastrointestinal endoscopy, biopsy |
| 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | GC | This service has been performed in part by a resident under the direction of a teaching physician | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2017-01-01 | Changed | Moderate (Conscious) Sedation flag removed. See new Moderate Sedation category. |
| 2014-01-01 | Changed | Description Changed |
| Pre-1990 | Added | Code added. |
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